Automated Medication Dispensing Cabinets, Errors, and Just Culture

By Beth Lindsey VanOrsdale, PhD, RN, DNP, MHA, CPHRM, CNE
Southern New Hampshire University Associate Dean of Health Professions

Pharmacy, nursing, respiratory therapy, and other healthcare professionals juggle multiple demands when reviewing, preparing, dispensing, and administering medications. For example, they’re simultaneously answering call lights and phone calls, helping a patient to the bathroom, and responding to emergencies. 

As clinicians we pride ourselves on being able to multitask through all these demands, and also rely on systems such as automated dispensing cabinets (ADCs) to add a layer of safety to our practice. While we appreciate and know that ADCs do provide additional safety, are we doing all we can to maximize that safety? And how are we treating clinicians who make an unfortunate medication error? Is our first reaction to lay blame and get rid of the “bad egg?” Do we thoughtfully analyze what factors caused the error?

Benefits and challenges of using automated medication dispensing cabinets (ADCs)

ADCs were introduced in the pharmacy in the 1980s with expanded deployment to care settings in the 2000s. Let’s look at what automated dispensing cabinets have done for us in addition to being the primary way medication is now dispensed in most health systems. We have:

  • Improved workflows for pharmacy and staff
  • Reduced wait time for drugs from the pharmacy
  • Streamlined billing
  • Achieved greater inventory control

Studies show that ADCs save a nurse an average of 32 minutes per eight-hour shift, allowing for more time with patients. Clinicians say their work is easier and more efficient with ADCs. There’s no question that ADCs bring significant benefits to the healthcare table.

From a healthcare administration standpoint, when we make rounds and see ADCs in hallways and medication rooms, we often feel comfortable knowing that we have invested in equipment that brings efficiency and safety. But before we become too comfortable in thinking that this technology will always help us beat the odds of making a medication error, let’s review the other side of the coin.

We must recognize that several vendors manufacture ADCs, and each model has a wide variety of capabilities, storage, software, and workflows. On the surface, all cabinets operate sing the same concept. But their functionality is not standardized—an important point considering many clinicians work at multiple sites and/or in multiple organizations.

Think of ADCs as akin to mobile phones; some organizations will have "the iPhone" and others will have "a Samsung Galaxy." Both work similarly in that they make calls, access the internet, use apps, and take photos. But how I go about performing those functions in each technology could be vastly different. Likewise, ADCs come in various models that routinely require updates. Add to that technological mix new staff due to turnover, shorter orientation periods, traveling nurses, and providers who work at multiple sites with different ADCs, and you have the perfect storm for an error around the use of an ADC.

We know about some common errors related to ADCs:

  • Incorrect medication is loaded into the ADC pocket, generally by pharmacy staff but also by “a helpful clinician” who withdrew the wrong item and wants to be orderly and returns it
  • Excessive use of overrides to obtain medication from the ADC
  • Removing medication outside of the patient profile, such as during the inventory function
  • Failure to recognize look-alike names in the pick list—diazepam and diltiazem, for example
  • Items with look-alike names and packing stored in close proximity 
  • Overutilization of open-drawer configurations without restricted access pockets, particularly for high-alert medications and controlled substances

Adopting Just Culture to prevent errors

When a medication error occurs, big or small, our best course of action is to look at what led to the set of system circumstances allowing it to happen. Recreating the situation, particularly in a physical demonstration at the ADC, will assist in finding the multiple contributing factors to the error. 

A key question to ask is, “Why didn’t the system prevent the error?” A root cause analysis (RCA) conducted by both pharmacy and clinicians will bring forward valuable issues to correct and to make improvements. How we go about the RCA and the tenor of the investigation is critical. 

First, a clinician may be devastated that an error has occurred on their watch, and they may have inherent fear that they’ll be disciplined, fired, or reported to a state board. Leading practices say don't blame the clinician or assume they should have known better.

Medication errors are rarely due to one human mistake, but instead are the result of multiple systems issues. However, too often when an error occurs, the person who can be marched to HR for dismissal or reported to the state licensure board is the person who gave the medication. When an error occurs, it’s crucial to understand the combination of human and system factors that contributed to the event. That’s where the concept of Just Culture comes in.

This model from David Marx reimagines accountability in a different way and works to understand errors to prevent them from reoccurring. The concept requires buy-in from multiple departments in the organization including HR, the C-suite, risk management, quality, and legal. Leaders must agree that the more we know about the multiple factors in the error, the better equipped we’ll be to create systems and processes that prevent errors.

How does Just Culture work?

What happens to the person who was involved in an error in a Just Culture environment? An algorithm is generally used to evaluate culpability of the individual involved. Examples include examining a wide variety of issues, including purpose, for instance:

  • Did the clinician have the express goal of causing harm? 
  • Did the clinician know that giving this medication would cause harm?
  • Was the error reckless, at-risk behavior, or an inadvertent mistake?  

In true human errors with an inadvertent action, we change processes and procedures, change design, and/or provide additional training with the goal of prevention. As leaders, we console the individual involved in the error. 

With at-risk behavior where a clinician makes a poor choice, fails to not recognize the risk, or believes the risk is justified, we coach them to increase their awareness of risk in a non-punitive way. When a clinician exhibits reckless behavior, remediation, punitive action, or punishment is the recommendation. If I came to work and administered the incorrect medication to a patient while I was under the influence, my consequences for a medication error would be greatly different and more severe than my consequences for an error where I was poorly trained on the use of the system.

Some people or departments are reluctant to adopt Just Culture or any of its many variants. Ideologically, some leaders want someone held accountable regardless of the multiple factors that led to the error. Unfortunately, some leaders view Just Culture as “no blame” and  as acceptance that mistakes just happen. But in reality, when instead the focus is on reporting errors in an open and transparent organization, the goals are to understanding the error and prevent future errors.

How to jumpstart Just Culture

Just Culture is now over 20 years old and is the industry standard to promote safety. However, many healthcare organizations have not adopted the philosophy or fail to use it in practice. But let’s not forget that Just Culture is not just about reacting to errors and harm; it also focuses on prevention.

Where can you start? Critically analyze at your organization: 

  • How well are you reviewing your medication error data? 
  • Has pharmacy and nursing recently dispensed medication from the ADC to make observations together regarding the ADC functionality and use? 
  • When was the last time the pharmacy and those staff dispensing medications (primarily nurses) did a round of medication administration together to see what problems they encountered? 
  • Do the pharmacy and nursing teams collaborate on the override reports to find areas of improvement? 

By working together, we will find situations where errors are waiting to happen. We can then establish the competencies and leading practices for the organization and redesign problematic processes. For example, we can find those excessive override requirements that allow our brains to push through the warning from the ADC. 

As leaders, we must ensure that preventative fact-finding activities happen. But we also have a responsibility to allow our employees to design good systems so that the system helps the employee make better choices—all while remembering that our workforce is human.

We’ve experienced more than two years of pandemic-related stress on both healthcare systems and on individual clinicians. Organizations must now pause and reflect on where they are in their journey to analyze medication errors and foster routine collaboration between nursing and pharmacy to proactively find problems. We are past time for more action.

For more information on how symplr can help your facility or organization achieve a safer environment for patients, nurses, and every participant across the care continuum, visit the symplr Patient Safety solutions page.Let's Get Started

Dr. Beth Lindsey VanOrsdale is the associate dean of health professions at Southern New Hampshire University. She has worked as a healthcare consultant and risk manager/patient safety officer at numerous healthcare organizations. She has a doctorate of nursing practice from American Sentinel University and is a Certified Nurse Educator and Certified Professional in Healthcare Risk Management. SNHU does not endorse or sponsor any commercial product, service, or activity offered on this website.

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